DESK REVIEWS | 02.02.07. Out-of-pocket expenses

DESK REVIEW | 02.02.07. Out-of-pocket expenses

It seems not to have official estimates about the proportion of the population incurring out-of-pocket payments for health services. However, a study conducted by the Credit Protection Service Brazil (SPC Brasil) and by the National Confederation of Stores Owners (CNDL) with 1,500 people from large capitals showed that, from the 70% of people who did not have private health insurance, 25% made out of pocket payments for private services (CNDL, 2018).


CNDL. (2018). Gastos dos Brasileiros com Saúde.

A study indicates that overall the proportion of households with catastrophic health expenditure “increased 1.47-fold between the NSS 1993–1994 and 2011–2012 expenditure surveys, and 2.24-fold between the NSS 1995–1996 and 2014 utilization surveys” (Pandey et al., 2018).


Pandey, A., Ploubidis, G. B., Clarke, L., & Dandona, L. (2018). Trends in catastrophic health expenditure in India: 1993 to 2014. Bulletin of the World Health Organization96(1), 18–28.

Out-of-pocket expenditure in Indonesia is significant and despite the introduction of social health insurance in 2014 remains one of the main funding sources for health care. In 2013, it was estimated to be 49 per cent out of total health expenditure; however, the figure has been reported to have declined to 34 per cent in 2017.

Despite this high proportion, the share of families facing catastrophic out-of-pocket expenditure (more than 25% of household expenditure) remains at only about 1 per cent. On the other hand, approximately 7 million households (8% of households) were reported to have been impoverished due to health-related out-of-pocket payments (World Bank, 2016b, p.4). The WHO, therefore, groups Indonesia among countries with high out-of-pocket expenditures (Agustina et al., 2019, p.85; WHO, 2017, pp.126,133; World Bank, 2016b, p.4).

Even though access to services is increasing, there appears to be a lack in uptake with about 50 per cent of those entitled to outpatient care and 20 per cent of those entitled to inpatient care not taking up services. This may be due to issues with access, waiting times, quality of care, and providers falsely charging for treatments and medication (Agustina et al., 2019, p.90).


Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102.

World Bank. (2016b). Indonesia Health Financing System assessment: spend more, spend right & spend better.

World Bank. (2017). Indonesia Can Improve Opportunities for and Protection of Its Migrants Working Abroad. Press Release.

The number of patients who for pay health services out of pocket is very high. It amounted to 26.11% out of the total health expenditure in 2014 (Index Mundi, 2019a). The high costs incurred from out-of-pocket health expenditure pose a barrier for Kenyans accessing healthcare services because it drives the poorer households into poverty. The costs of treatment continue to limit the access of care especially by the poor. The Ministry of Health estimates that 16% of the sick do not seek treatment due to financial constraints, while 38% of them must sell some of their assets or borrow in order to finance their medical bills (Luoma et al., 2010). In Kenya, one has to directly pay for health services at the point of consumption. This led to 7.1% of households in Kenya to face catastrophic expenditures and increased the poverty head count by 2.2% due to OOP payments in 2018 (Salari et al., 2019).


IndexMundi. (2019a). Kenya – Out-of-pocket health expenditure (% of total expenditure on health).

Luoma, M., Doherty, J., Muchiri, S., Barasa, T., Hofler, K., Maniscalco, L., … Maundu, J. (2010). Kenya Health System Assessment 2010. Health Systems 20/20 Project, 20(August), 1–133.

Salari, P., Di Giorgio, L., Ilinca, S., & Chuma, J. (2019). The catastrophic and impoverishing effects of out-of-pocket healthcare payments in Kenya, 2018. BMJ Global Health, 4(6).

A consequence of low levels of government health spending, is the relevant participation of the private market. Most of this privately purchased health care is paid through out-of-pocket transactions, as private insurance makes up a very small segment of the market (approximately 4% of total health expenditures). Mexico has the highest out-of-pocket share of total health care spending among OECD countries: out-of-pocket health spending (paid directly by patients) in 2017 reached 40.4% of total spending (OECD, n.d.; OECD, 2016b).

Despite slightly decreasing from 55% in 2005, out-of-pocket health spending (paid directly by patients) in Mexico in 2017 still amounted to 40.4% of total spending. As a result, the high burden of out-of-pocket spending continues to create financial barriers to health care access, particularly for the low-income population. In this same year, government/compulsory health spending represented 51.6% of total health expenditures, while the remaining 8% corresponded to health expenditures by the voluntary sector (NGOs and private corporations) (OECD, n.d.)


OECD. (n.d.). Health data. Retrieved March 16, 2020, from

OECD. (2016b). OECD Reviews of Health Systems: Mexico. In OECD Publishing (Ed.), OECD Reviews of Health Systems (OECD Reviews of Health Systems). OECD Publishing.

Out-of-pocket payments comprise approximately 29.7% of private healthcare expenses (WHO, 2011c as in (EMERALD, 2017).


EMERALD. (2017). Moving towards Universal Health Coverage for Mental Disorders in South Africa.